Provider Demographics
NPI:1619243987
Name:DECATUR FAMILY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:DECATUR FAMILY MEDICAL GROUP INC
Other - Org Name:CORNERSTONE FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-422-3702
Mailing Address - Street 1:3708 SIMS DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-9200
Mailing Address - Country:US
Mailing Address - Phone:217-422-3702
Mailing Address - Fax:
Practice Address - Street 1:440 SUNSET CT STE C
Practice Address - Street 2:
Practice Address - City:MT ZION
Practice Address - State:IL
Practice Address - Zip Code:62549-1556
Practice Address - Country:US
Practice Address - Phone:217-864-1236
Practice Address - Fax:217-864-1470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103155261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1871599522OtherPROVIDER'S NPI
1871599522OtherPROVIDER'S NPI